<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602219
Report Date: 12/19/2023
Date Signed: 12/19/2023 02:07:58 PM

Document Has Been Signed on 12/19/2023 02:07 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:AMBITIONS - 183RD STREETFACILITY NUMBER:
198602219
ADMINISTRATOR:LESLYN VENEGASFACILITY TYPE:
735
ADDRESS:11417 183RD STTELEPHONE:
(562) 219-5799
CITY:ARTESIASTATE: CAZIP CODE:
90701
CAPACITY: 3CENSUS: 3DATE:
12/19/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Baltazar Cornejo TIME COMPLETED:
02:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Ashley Calderon conducted an unannounced continuation case management visit to continue the annual inspection. During today's visit LPA used the CARE inspection Tool. LPA met with Administrator Baltazar Cornejo and explained the reason for the visit.

The following was observed, reviewed and inspected:
    • Medication's were reviewed for (3) clients in care. Medications are kept locked and inaccessible to clients in care. Medications are located in cabinet door in living room. LPA observed medication error for client #3.
    • LPA observed: sufficient about of linen/towels are available for clients to permit changing at least once a week.
    • LPA observed : hallway bathroom cabinets have sufficient client hygiene supplies for clients in care.
    • LPA attempt to interview (3) client's present at the facility during time of visit.
    • LPA reviewed (3) client files, client files / documentation's, which weren't complete for Client #1-Client #3.
Due to insufficient time, visit will continue at a further time.

Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies were cited
on LIC809-D. Exit interview held and a copy of the report will be provided to Administrator via email.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 12/19/2023 02:07 PM - It Cannot Be Edited


Created By: Ashley Calderon On 12/19/2023 at 01:10 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: AMBITIONS - 183RD STREET
FACILITY NUMBER: 198602219

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(e)(2)
87465 (e)(2) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication.

This requirement is not met as evidenced by: Medication listed ( Polyethylene Gycol. 3350 Powder / RX#555364) on Medication Record log for client #3 did not have a physician’s order in place, no instructions and has not been taken based on Medication Record December 01,2023. Medication was not present at the facility.
Deficient Practice Statement
1
2
3
4
Based on observation, interview with Admin., record review, the licensee did not comply with the section cited above in [1] out of (3) persons, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/19/2024
Plan of Correction
1
2
3
4
Administrator during time of visit made an appointment for client #3, Administrator via email will submit an update status of medication based on instructions from Physician.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Fernando Fierros
LICENSING EVALUATOR NAME:Ashley Calderon
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 12/19/2023 02:07 PM - It Cannot Be Edited


Created By: Ashley Calderon On 12/19/2023 at 01:44 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: AMBITIONS - 183RD STREET
FACILITY NUMBER: 198602219

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(a)
80070(a) Client Records. The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client. This requirement was not met as evidenced by:
This requirement is not met as evidenced by: Client #1-Client #3 had missing documenations in client files.
Deficient Practice Statement
1
2
3
4
Based on observation and record review for clients, the licensee/ facility did not comply with the section cited above in [3] out of [3] persons/ files, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2024
Plan of Correction
1
2
3
4
Administrator will submit copies to LPA via email documenations for clients: Client #1 for Client #2 Admissions Agreement, Physician Report/ TB (LIC602), recent IPP or Appraisal Needs and Service Plan (LIC625) and Personal Rights (LIC613-C), Inventory List (LIC621) / Client #2 Admissions Agreement, Physician Report/ TB (LIC602), recent IPP or Appraisal Needs and Service Plan (LIC625) and Personal Rights (LIC613-C), Inventory List (LIC621).
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Fernando Fierros
LICENSING EVALUATOR NAME:Ashley Calderon
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2023


LIC809 (FAS) - (06/04)
Page: 3 of 3